Rates of electronic cigarette use among patients with cancer have risen over the past several years as rates of conventional smoking have remained steady, according to survey results reported in a research letter published in JAMA Oncology.

“[E-cigarettes] have become increasingly popular in the United States and are advertised as a potentially safe and useful method of smoking cessation, despite unknown long-term health sequelae,” Nina N. Sanford, MD, assistant professor in the department of radiation oncology at University of Texas Southwestern Medical Center, and colleagues wrote. “Individuals with cancer are particularly sensitive to the harms of active smoking, thus smoking cessation is a critical component of cancer survivorship. However, the patterns and implications of e-cigarette use in patients with cancer are not well-known.”

Results showed that from 2014 to 2017, the rate of e-cigarette use increased from 8.5% to 10.7% (P = .01), whereas the rate of conventional smoking remained steady, from 50.7% to 51.9%.

“This is a relatively short time period and the database we used does not accurately capture quantity of smoking, so perhaps cancer patients and survivors are smoking less, but not none,” Sanford told HemOnc Today. “Either way, the stable rates of conventional smoking does cast doubt that e-cigarettes are an effective method of smoking cessation in this population.”

The years 2016 and 2017 appeared associated with increased odds of e-cigarette use (adjusted OR [AOR] = 1.26; 95% CI, 1.01-1.57).

Researchers observed the association between e-cigarette use and higher likelihood of use for years 2016 and 2017 among patients younger than 50 years (AOR = 1.71; 95% CI, 1.17-2.51) but not in patients age 50 years or older (AOR = 1.05; 95% CI, 0.82-1.35). E-cigarette use between 2014 and 2017 increased from 22.8% to 26.8% in patients aged younger than 50 years and from 6% to 8% in patients aged 50 years and older. E-cigarette use among former smokers increased from 5.8% to 8.3% during this period.

“I am concerned that e-cigarette/vaping use will continue to increase among younger folks. First, because they can contain nicotine, which is highly addictive, so those who have already started using them are likely to continue,” Sanford told HemOnc Today. “Second, [I am concerned by] the attractive marketing tools employed specifically to entice the younger population. I think their popularity will continue to increase until there is documented evidence of their long-term harm — either directly from e-cigarettes, or from e-cigarettes as a gateway to conventional smoking.”

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Most of the participants were white, and the data were self-reported, which served as limitations to this study.

“Among the general population, experts worry that e-cigarettes may be creating addiction to nicotine among younger individuals who are at risk of prolonged exposure,” Sanford and colleagues wrote. “Our findings prompt similar concerns regarding potential deleterious long-term consequences on oncologic outcomes and survivorship, including the potential for increased cancer risk, for which further investigation is needed.” – by John DeRosier

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Perspective

Perspective

With the dramatic increase in e-cigarette use in the general population, especially among young people, more attention has been devoted to behaviors surrounding this newest class of tobacco products. The authors conclude that from 2014 to 2017, the rates of e-cigarette use increased, especially among former smokers and those aged younger than 50 years, whereas the rate of combusted tobacco smoking remained flat.

Some important issues should be noted.

First, the mean age of the population was 68 years, which is not surprising considering this was a sample of patients with cancer. The generally older ages of the sample could influence the overall e-cigarette rates.

Second, it is unclear if the query about e-cigarette use referred to ever use or current use, although the high rates (9.5% overall) suggest ever use.

Third, although e-cigarette use did increase over the period, from 8.5% to 10.7%, it is important to note that the smoking rate was between 50.7% and 51.9% — significantly higher than the e-cigarette use rate.

Fourth, as expected, the odds of e-cigarette use were much higher among those aged younger than 50 years (AOR = 3.79) and the positive association between later survey year and e-cigarette use was only seen in those younger than 50 years (AOR = 1.71). In this age group, e-cigarette use increased from 22.8% to 26.8% over the years of the study (P = .01).

Finally, the increase of e-cigarette use was only significant among former smokers, rising from 5.8% to 8.3%. What is unclear from this final point, and unable to be determined from these data, is whether e-cigarette use contributed to those smokers stopping combusted tobacco smoking or if it had no causal impact. The authors caution that we do not know the long-term health effects of e-cigarette use among patients with cancer, as well as among the general population, and that we should be screening for e-cigarette use.

Based on the 2018 report from the National Academies of Science, Engineering, and Medicine, which is the most complete collection of evidence to date regarding e-cigarettes, these products likely represent lower harm than combusted tobacco; however, they are not safe, and the long-term health effects of their use is unknown. Additionally, there is a lack of substantial evidence to demonstrate efficacy for smoking cessation.

E-cigarette use is clearly an important public health issue in these times and warrants inclusion in oncology assessment. However, we must not lose sight of the dramatically greater harm that smoking combusted tobacco continues to be for patients with cancer diagnoses, and we should do everything we can to help those patients stop smoking, starting with evidence-based, comprehensive interventions and FDA-approved treatments.